Job Summary
This position reviews clinical information and conducts audits of billings to determine appropriateness of charges in accordance with contracted payor terms, standards of care and insurance policy parameters. Works with physicians, patients, payors and other healthcare providers support appropriate utilization of healthcare services. Provides clinical knowledge to assist billing and collection team members in responding to insurance denial of billings.
Essential Functions
Evaluates and intervenes concurrently and retrospectively for level of care, coverage issues, payor outliers, split billing, disallowed charges, patient inquires, denial and compliance issues.
Initiates actions and participates with Patient Financial Services payor teams regarding resolution of denial management issues or compliance issues. Works with authorized payors or reviewers to resolve denial management issues, reconsiderations and appeals.
Tracks, monitors and documents denial causes and resolutions with appropriate management staff.
Acts as a knowledge resource for billing staff members. Identifies educational needs regarding payor issues, functions as preceptor, and provides appropriate education.
Builds and continually updates a knowledge of Third Party Payor requirements for covered treatment protocols by diagnosis, approval requirements for procedures, and coverage norms.
Provides education by collaborating with Care Coordination at company facilities or other staff of non-company locations on concurrent and retrospective utilization review. Accurately and thoroughly completes documentation required for claims payment of services approved through concurrent review and case management.
Minimum Qualifications
Requires Registered Nurse (R.N.) licensure in the state of practice. In a Behavioral Health setting requires Registered Nurse (R.N.) licensure in the state of practice or a current Arizona Board of Behavioral Health Examiners License based on an accredited Master's degree.
Requires five or more years of clinical nursing or related experience or, in a Behavioral Health setting, Master's level Social Work in healthcare, behavioral health counseling, or related experience. Experience in evaluation techniques, teaching, hospital operations, reimbursement methods, medical staff relations, and the charging/billing process is required. A working knowledge of utilization management and patient services is required. A working knowledge of Medical and third party payor requirements and reimbursement methodologies is required. Employees working at Banner Behavioral Health Hospital must possess an Arizona Fingerprint Clearance Card at the time of hire and maintain the card for the duration of their employment.
Highly developed human relation and communication skills are required. Excellent organizational, written and verbal communication skills are essential for this position.
Preferred Qualifications
A Bachelor of Science degree in Nursing is preferred.
Additional related education and/or experience preferred.
